Overdoses on the Rise

A brief quiz: what was the leading cause of injury death in the United States last year? It’s not car accidents. It’s not falls. In fact, it’s ironically influenced by the use of health care services.

A recent CDC study discovered that more than 47,000 Americans died from drug overdoses in 2014, the highest incidence in the nation’s history. Overdose deaths were more prominent across nearly all demographics—both non-Hispanic whites and blacks, men and women and people aged 25-44 and 55 or above. What’s more, this rise occurs on top of the broader surge of overdose deaths occurring since the late 1990s.

With such a staggering rise in incidence, drug overdoses can be legitimately qualified as an epidemic. The question is, what is the cause?

A Familiar Culprit

Among all drugs, the opioids stand out in the current epidemic. According to “Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014” by Rudd and colleagues, 61 percent of overdose deaths in 2014 were caused by opioid pain relievers or heroin, and the number of Americans dying from prescription opiate overdoses has more than quadrupled since 1999.

Opioids fall under the broad class of drugs known as analgesics, or painkillers. Drugs like acetaminophen, ibuprofen and aspirin fall in this category and have a low toxicity, mild side effects, well-defined safe clinical dosages and, in most cases, are sufficient for pain management. However, for more serious pain, such as that caused by cancer, osteoarthritis or neuropathy, prescription opioids are the standard solution.

However, opioids are not a newcomer in the medical field. As far back as 4000 B.C. among the Sumerians, opioids have been utilized for their physical and psychological effects. All opioids are derivations or synthetic replications of the naturally grown opium poppy[1], and common medical renditions include morphine, codeine, fentanyl, hydrocodone and methadone. Similarly, heroin, an illegal drug with a greater potency than most prescribed opioids, also falls into the opioid class.

Unlike aspirin or ibuprofen[2], opioids act directly on receptors in the reward centers of the brain—the same ones acted upon by endogenous opioids known as endorphins—and, along with pain relief, can induce symptoms of euphoria, general calming and slowed respiration. With steady use over time, the body begins to produce fewer endogenous opioids, leading to withdrawal symptoms and a heavy potential for addiction.

Furthering opioids’ dangerous potential is their ability to rapidly induce tolerance. Upon repeated stimulation, the body’s opioid receptors become desensitized and higher drug doses are needed to achieve the same feeling of euphoria. Unfortunately, the respiratory depression caused by opioids doesn’t exhibit the same tolerance. When a user’s dose is raised too high, respiration can slow to the point of death.

A Medical Origin

America is no stranger to problems of drug abuse. Surges of drug use have occurred sporadically throughout history, but never before have healthcare providers—professionals toward whom people look for health solutions—been such a major source of the problem.

In brief, a major factor of the current epidemic is overprescription.

In 1997, two expert panels of anesthesiologists released new guidelines that advocated for the expanded use of opioids as a means of pain management. In the decades that followed, prescriptions of opioids rose dramatically. Today, America holds less than 5 percent of the world’s population and yet it consumes roughly 80 percent of the world’s opioid supply, according to 2008 study published in Pain Physician. It’s no secret that Western physicians are more liberal in prescribing medications, but the prescription of opioids is especially unique. For one, primary care providers (PCPs), not pain management specialists, are the leading prescribers of opioids. While PCPs are educated about the proper uses of such medications, they lack the intimate familiarity with opioids that pain management physicians acquire through years of training. As a result, PCPs may not be aware of the nuances of proper opioid prescriptions that are necessary to reduce the potential for addiction.

Furthermore, patients who suffer from chronic pain also suffer other comorbidities that require medication. Drugs such as benzodiazepines for anxiety or muscle relaxants for spasms have synergistic effects with opioids, dangerously sedating the respiratory system in particular. Even if one physician properly prescribes an opioid, the same patient may receive different prescriptions from other specialists, compounding the negative effects. As an Express Scripts study found, 29 percent of long-term opioid users were also prescribed benzodiazepines, 28 percent concurrently took muscle relaxants, and 8 percent used all three at once.

From a continuance standpoint, certain opioids are intended for short-term use while others are more appropriate for chronic pain management. When improperly prescribed or consumed, opioids can become stepping-stones to other drugs of abuse, especially heroin. In a study of Americans suffering from opioid addiction, Kolodny and colleagues found that about 75 percent ultimately switched to heroin as a cheaper and more available opioid source. Once they have started recreationally using this potent, unregulated drug, a deadly overdose is even more likely.

Healing the System

The opioid epidemic has recently become a priority for many public health officials. In a December 2015 report, the CDC proposed a plan of action to address the issue, which involves coordination among physicians, addiction treatment specialists, public health agencies and law enforcement officials.

As with any public health treatment plan, the CDC recommendation includes examples of primary, secondary and tertiary intervention. Primary intervention prevents exposure to the issue. Examples in this case include more judicious prescription of opioids by physicians, improved drug education for children and reduction of heroin availability. Secondary intervention can be thought of as catching cases early, before they become too serious. Applied to opiate abuse, the CDC implores physicians to closely monitor opioid-using patients for signs of abuse. At the same time, according to Kolodny and colleagues, improved communication between healthcare providers must be stressed, possibly with the use of state-run databases known as prescription drug monitoring programs.

Lastly, tertiary intervention measures are employed after a disease has taken hold. Both harm-reduction and rehabilitation efforts will be integral in treating the opioid epidemic. Fortunately, treatment methods for addiction are plenty and combinations of psychosocial treatments with pharmacological therapies have proven effective. Drugs like methadone and buprenorphine can reduce cravings while the increasingly popular drug, naltrexone, is an antidote for opioid overdoses as well as a means of blocking opioids’ euphoric effects—a particularly helpful manifestation for those trying to break a pattern of chronic use.

Despite the daunting statistics, the opioid overdose epidemic is far from untreatable, and it all starts with education. Promoting an improved understanding of both the benefits and hazards of these potent drugs, physicians and patients can use them to change lives for the better.

[1] The term “opiates” refers to natural derivatives, while “opioid” refers to synthetic opiates and the class of drug that encompasses both natural and synthetic forms. For clarity, I will simply use the term opioid in reference to the broad class of drug in this article.

[2] And possibly acetaminophen, as its exact mechanism of action remains unknown